Provider Demographics
NPI:1710270475
Name:BERGMAN, TANNER MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:TANNER
Middle Name:MICHAEL
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:TANNER
Other - Middle Name:M
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, NCC
Mailing Address - Street 1:2816 NW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2107
Mailing Address - Country:US
Mailing Address - Phone:405-410-8162
Mailing Address - Fax:
Practice Address - Street 1:1442 NW 46TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4802
Practice Address - Country:US
Practice Address - Phone:405-410-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6236101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional